 Hi, everybody, this is Donna Prosser with the Patient Safety MIMMA Foundation. Today, we're here to talk about the impact of handoff communications on patient safety. And we're really excited to be joined by Dr. Annegrette Hanawa. She's a professor of communication science at the University of Lugano, Switzerland. Welcome, Annegrette. Nice to be here. Thank you, Donna. Now, Annegrette, you are a communication scientist. And you direct the only patient safety center in a communication science department at a university. You founded a global research center that combines communication science with patient safety research. And you've also delivered some groundbreaking research yourself over the last decade. So tell us, what does communication play in patient safety? What role does that play? Well, it's omnipresent, right? So it's the vehicle for which health care takes place. We need communication for everything that we do. So in that sense, it really starts with history taking. It goes over diagnosis, treatment planning, treatment execution, post-treatment care, all the way up to discharge. And then, of course, as a preventive function in those contexts. And then also, when we look at the disclosure of adverse events, for example, we look at communication as an urgent or a safety critical competency there as well. So it's everywhere. And so the goal has become lately to optimize communication, as I said, both as a preventive function as well as for safe disclosure. So you mentioned preventive communication. What interventions have been done so far? So quite a few. And as we're talking about hand-ups today, of course, that's been a critical context in patient safety that we've been looking at. And so we've had multiple tools of frameworks that people have introduced. And of course, one of the most advertised one is TeamSTEPPS. And within that, of course, there's four skills embedded in that framework. And one of them being communication. And among those communication skills, there's four different sets of techniques that have been introduced. And if you will have a slide that you can look at right now. So if we go up from the bottom, there's call-outs, which is for communicating important or critical information to other team members, such as airway status clear, breath sounds decreased on right, blood pressure, 96 over 62, and so forth. Then we have check back, which goes into closed-loop communication. In my sense, it's one of the most important things to look at. Of course, it's about validating message receipt. So we're closing that circle of communication. And then one further up is a team communication tool, SBAR, which has been implemented all over the world. SBAR stands for Situation Background Assessment and Recommendation, which is, again, for communicating critical information. Within the team, though, it's not a hand-off tool per se. And then we have, of course, the iPass mnemonic, which is a linear way of standardizing and structuring communication in terms of structuring the content for hand-offs. And that looks as the eye stands for illness, severity, and then patient summary, actionless of what's to do, situation awareness with event statements. And then for me, again, the most critical part is the synthesis part, where the receiver repeats what was said, can ask questions, can confirm the action that needs to be taken place. So all that is kind of a linear assumption again, and that we kind of go through those processes, through those content categories to cover the basics. And it really, all these mnemonics serve kind of a recall or reminder for the staff to make sure that all the important information gets covered. So whatever those mnemonics serve quite well, there's lots of them. So this is just one of the examples. But as I said, now, IPaS has probably been tested most among the ones that have been available, although only few experimental studies have been done today to test the effects of IPaS on objective outcomes, particularly at adverse events. Sort of the golden key study that we've seen there, of course, in the New England Journal of Medicine, reported a 30 degrees in the rate of preventable adverse events, but only a two thirds of the investigative sites. And what I'm missing is the effect sizes haven't been reported in that study, but it's a start. But I still think that there is more research needed to be done to really look at patient safety outcomes as well. So why have preventive communication interventions not been successful up until now in solving our communication problems? Well, they have been successful to some extent, but I think there's a long way to go to look at larger effects of interventions. And I think one of the reasons why we haven't achieved as much as we could have is the fact that these mnemonic devices or these tools and frameworks that have been introduced, they've always been context specific and kind of problem focused. For example, the problem of handoffs or the problem of disclosure or the problem of bad news delivery, right? So they've always been tied to particular contexts. And so there's also no one handoff mnemonic that is ideal for all handoff situations, right? So we've seen variability there as well and there's no evidence that any one mnemonic is better than the other and really affecting patient safety measures. For me particularly, one of the biggest issues is that as we're teaching mnemonics instead of kind of the, we'll talk about that later, that their shared sense-making skills is that we're cluttering medical students as a nursing student's minds, right? Because they have to remember so many different mnemonics for different types of context that it could be really challenging for them to really grasp them and practice them as skills rather than something that's purely brain driven. So for me, I think that there's a path for development open there where we can look at something that applies to all care stages and all contexts and really strengthening that interpersonal sense-making process as a resilience enhancing skill set and rather than just looking at fixing little context specific issues like we're putting a prosthesis in a knee or something like that. So I think that's where we still have opportunity for growth. So what's the path forward there? How do we get to that place? Well, I think we first need to recognize the problem of the problem, right? And I think that there's a couple of pieces to that. First of all, we need to recognize that communication is not a synonym for information. I think still in the literature, oftentimes we see that being a metaphor. Like communication is just like a car that breaks down or a telephone that fails to operate. So I think that the first start is to recognize that communication is much more interactive than just sending a message and making sure it arrives as it was intended, but it's a very dynamic interactive mechanism then also of course now with digitization, right? That's increasing the problem because also with digitization, it rides on that assumption that communication is linear. So I think we need to be careful that we're using digitization tools for enhancing that interpersonal sense-making process rather than just running on that same problematic path that we've been arguing on. And then also recognizing that communication is not a problem, it's a human condition, right? So we communicate everywhere and not very well. That's in communication science, we research lots of different contexts of communication problems. You see workplace bullying, you see intimate violence, domestic violence. You see so many issues that we're researching and healthcare is just one other context where it gets dangerous just like in the airline industry because failures there threaten lives. So I think that if we realize that the healthcare setting is very unique and that there's many people on different backgrounds coming with variable linguistic and cognitive skills into one place and they have to interact quickly, many times a day under the pressure of distracting noises, limited privacy and oftentimes life and death situations. And that's just not a fertile ground for safe communication to just take place naturally. So I think that once we've recognized that problem of the problem, then we need to approach it with more of a fundament of that as I said that I like to call it an interpersonal sense-making process as a resilience enhancing safety feature, right? So that we're teaching or learning core competencies. And so if we standardize anything, it should be standardizing the skills to get us to a shared understanding and not so much the mnemonics. And I think the mnemonics are very helpful and that they do in situations that are under high pressure make sure all the content gets covered but beyond that we need to make sure that as a fundament underneath those mnemonics interpersonal sense-making processes are resilient to failure. So you talked about core competencies and safe communication, what does that look like? So we've analyzed hundreds of patient safety cases to find an answer to that question, which is not that easy, but we came up with a pretty simple explanation. So what we found is that all patient safety events that we've looked at always reduce down to at least one of five communication things that go wrong. So those five we've turned into competencies to prevent them from going wrong. So that's how we approached it. And what we came up with is what we call safe communication as a context that we'll show up later on a slide, Sasha. But to understand first of all, what's the fundament for that, for those skills to happen is the understanding of how communication takes place. And that's pretty simple and many scientists probably at a university intro level of communication, but so what happens is we first get a thought in our mind that that's very complex, right? And our language is very abstract. So we have to take a very complex thought and put it into non-verbal and verbal codes and cues and to convey that thought to someone else so that then it can reassemble like a puzzle in their heads. And we kind of conduct that process as long as it takes for us to really come out with that same puzzle that we share when we look at it. So that's a communication process. So we call this in coding. So when I take that thought and I put it into non-verbal and verbal cues and send it to you, so to say, and you would decode that, that's decoding where you reassemble what I've disassembled to hopefully the same puzzle. And then we engage in the third process that's transactional sense-making where we make sure that we've done that process successfully so that we're actually recreating that exact same puzzle that we had in our mind. So that's the three processes through which communication takes place and that's an old knowledge that doesn't come from me, of course. So, but that as a fundament, we've found five different competencies. We've identified five different competencies that go both into quantity as well as quality of communication. And those three processes, as just explained are embedded in each of them. So the first one, and we'll put that slide up now and so you can follow through the Sasha framework which summarizes as an acronym of those five competencies. So the S stands for sufficiency which is about the quantity of the informational content that's included, right? So many of the mnemonics that we've looked at actually move in that realm of making sure enough content is covered. So, but again, with those three processes it's about conveying content, enough content, extracting enough content and also exchanging a sufficient amount of information with each other to arrive at a shared understanding, right? So safe communication is about arriving at a shared understanding. So that's what sufficiency as the quantity factor looks at. And then the other four are accuracy, clarity, contextualization and interpersonal adaptation that you see up on that slide and accuracy stands for not just conveying correct information or interpreting information correctly but also to utilizing that transactional sense making process for ensuring accurate information, right? So it's sort of a validation process that we can utilize between us and to validate the accuracy of the communicated content. And then we have clarity which is the next one where it's about, of course, again, expressing and also interpreting both verbal and non-verbal messages clearly so to avoid ambiguity in the way that we talk but also to utilize our communication with each other to reduce uncertainty, right? So it's an uncertainty reduction process. And then we have contextualization which in healthcare we found is the most frequent communication error that's happening is there's, as I mentioned before about the context of the healthcare setting being very complex. There's lots of contextual barriers that can hinder finding a shared understanding, right? So they're hierarchies. There's time pressure. They're possibly discrepant goals, right? A patient who's getting treated may not have the same treatment goal as the physician or the nurse dealing with that patient. So to what extent can we utilize our communication to neutralize these barriers so that we can actually achieve a shared understanding? And then the last one is the IA of Sasha is in a personal adaptation. So we've seen a lot in a sense of non-verbally expressed needs to which we need to adapt as listeners or as co-participants in the communication for us to really attain a shared understanding. If we don't, we're not going to arrive at a shared understanding, right? So there's different, it can be emotional needs. We've talked about handing an issue to the patient. For example, that's a simplified version of the problem, but there's also linguistics needs, for example. So if, or a cognitive processing speed differences or differences in education or experience and the healthcare setting that need to be adapted to so that we can actually attain a shared understanding with the other person. So these are the core competencies that we've kind of identified as fundamental resiliency enhancing processes, right? For improving the quality and safety of care. So that's, I think, one of the ways in which we could move forward and help those mnemonics to achieve higher effect sizes because then the mnemonics remain what they are in a sense of helping a recall function, a reminder function, a focusing function in contexts that are under time pressure that are critical. But at the same time, when those processes are trained well, then they can achieve much higher effects at the front line of care. Annegrette, last year you also had the experience of being a patient yourself. Can you tell us a little bit about that experience and how your Sasha framework could have improved the safety of handoffs? Well, it was, there's an article that's gonna come out in August now that you can free to post it on your network as well. In which I explained the frustration I had to experience being a communication scientist, having published for years on this topic and then witnessing how discouraging it is to be in the skin of a patient. So what I saw is two things. First of all, there were multiple handoffs I experienced even within the first few hours. I entered the emergency and then urgent care and then was delivered into my bedroom where I had a numb sensation of about 5% numb sensation in my arm. The first neurologist took it down as a tickling sensation, passed that off to the next physician. I corrected that physician said it was not a tickling sensation, it was a numbness, I felt. And then the next morning there was another handoff where that tickling sensation was then handed off as pain. And again, I again had to correct them and make sure that in their records they would correct that as simple thing that I had corrected before and it still wasn't corrected in the records when I was discharged from the hospital later on. So I was just really discouraged to see how such a simple thing as a sensation in your arm which is nothing compared to a much more complex scenario. I had a stroke so that was much more complex to understand already there the communication failed several times and me as a patient could not correct it. So that's the weakness I see in most of these handoff protocols is that the communication is reduced to the caregivers and the patient who's really supplying also non-verbally and verbally of course, as much as you can lots of valuable information to the safety of the care procedure is just bracketed out, right? And then there was another issue where they were following some sort of a weird as far procedure as a handoff, which was odd. And so they were so occupied. I don't know if it's because they realized I'm a communication scientist in the field or if they were just trying to do it really well I could tell I felt humbled by that, right? But they were so into their mononics that they didn't communicate anymore. And they were just, nobody was making eye contact everyone was just looking at the pen pad and taking down the notes and they went like a linear process through the end and then even the synthesis which should be the part where communication takes place was just another check on that list that they had to complete. And while they were going through this, there was a couple of things I wanted to correct among other things that tickling sensation and I tried to say something and they shut me up. They raised their hand at me like, you know stop sign and said, keep your thoughts to the end. We need to get through this otherwise things get confusing. And then in the end, you're welcome to add what you have to add. So at the end, the problem was we're out of time they had to leave. And second of all, they must have forgotten that as a acute stroke patient, my memory capacity was quite low. So I wouldn't even have been able to recall much of what I wanted to say. So that's just as I said before that not understanding communication enough as an interpersonal dynamic sense making process but rather as that conduit metaphor of that the phone line or like sending information through to the end and just leaving it up to best luck to get there is problematic. And so as I said before, I think that there's a lot we can improve there and talking about patient engagement or family activation I think it's critically important that it's more than just allowing the patient to listen but it's recognizing that the patient is part of the communication process. And if there is a shared understanding to be established you can't bracket out one of the communicators. That's right. Absolutely. Well, and that brings us to the topic of patient-centered care which we're all supposed to be focusing on anyway. And if we don't have the patient at the center of care then clearly they will not have as good outcomes. So, well, thank you so much, Anna Gret. This has been such great information and we really appreciate you sharing your Sasha framework with us. We will definitely be looking for your paper in August and be posting that on our website as well. Perfect. Thank you, Donna. Thanks for having me. Thank you, Anna Gret. Have a great day.